European Journal of Case Reports in Internal Medicine https://ejcrim.com/index.php/EJCRIM <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="http://www.efim.org/about/member-countries">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href="mailto:ejcrim@smc-media.eu">ejcrim@smc-media.eu</a></p> Life-Saving Combined Heart–Kidney Transplantation in a Previous Sequential Heart and Kidney Transplant Recipient https://ejcrim.com/index.php/EJCRIM/article/view/924 <p><em>Purpose:</em> Solid organ re-transplantation in the context of allograft failure is a challenging clinical and ethical problem. Ideally, solid organ re-transplantation after initial allograft failure should be performed in all recipients, but this is often not clinically or logistically feasible. <br> <em>Methods:</em> This report details what we believe is the first combined heart–kidney transplant in a recipient of a previous sequential heart and kidney transplant. <em>Results:</em> Eight years after a combined heart and kidney transplant after initially receiving a sequential heart and kidney transplant, a 31-year-old man is doing extremely well, with no rejection episodes or significant complications after transplantation.<br> <em>Summary:</em> This case confirms that combined heart and kidney transplantation is a viable option for tackling the complex issue of graft failure in recipients of previous cardiac and renal grafts.</p> Meenal Sharma Chris Anthony Christopher Hayward Andrew Jabbour Anne M Keogh Peter Macdonald Jacob Sevastos ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-06-19 2018-06-19 5 5 10.12890/2018_000924 A 32-Year-Old Woman with Relapsing Pneumonia https://ejcrim.com/index.php/EJCRIM/article/view/854 <p><em>Introduction:</em> Isolated right pulmonary artery agenesis in an adult patient is an extremely rare condition that requires a high level of suspicion to make the diagnosis. <br> <em>Case Description:</em> A 32-year-old woman presented to the emergency room with a 4-month history of recurrent respiratory infections. Chest radiography and computerized tomography (CT) revealed alveolar opacities on the medium and inferior right lobes. Fibreoptic bronchoscopy with bronchial aspirate was negative on both cytological and microbiological analysis. Due to the persistent of the imaging findings after a full course of a wide-spectrum antibiotic, an angio-CT was performed, revealing a complete stop at the level of the right pulmonary artery. Angiography confirmed the diagnosis of right pulmonary artery agenesis.<br> <em>Discussion:</em> Currently, the patient has no exertional dyspnoea, screening for pulmonary hypertension has so far been negative and no further respiratory infections have occurred. It is important to call attention to a major congenital malformation that may remain asymptomatic until adulthood.</p> Ana Rafaela Araújo Magda Sousa Joel Pinto Susana Cavadas Luís Rodrigues ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-06-14 2018-06-14 5 5 10.12890/2018_000854 Addison’s Disease Caused by Tuberculosis: Diagnostic and Therapeutic Difficulties https://ejcrim.com/index.php/EJCRIM/article/view/911 <p><em>Objectives:</em> To demonstrate difficulties in diagnosing and treating Addison’s disease caused by tuberculosis.<br> <em>Materials and methods:</em> We present a clinical case and review of the literature.<br> <em>Results:</em> A 62-year-old man presented with gastrointestinal symptoms, weight loss and enlarged adrenal glands. After 2 months of diagnostic tests, a working diagnosis of Addison’s disease due to extrapulmonary tuberculosis was made. Treatment was challenging due to interaction between rifampicin and steroids. <br> <em>Conclusion:</em> Our case illustrates that in non-endemic countries, extrapulmonary tuberculosis still needs to be considered as a possible cause of Addison’s disease.</p> Sanne van Haren Noman Hannah Visser Alex Muller Gijs Limonard ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-06-12 2018-06-12 5 5 10.12890/2018_000911 An Unusual Presentation of Deep Vein Thrombosis https://ejcrim.com/index.php/EJCRIM/article/view/899 <p>May–Thurner syndrome (MTS) usually presents as acute or chronic deep vein thrombosis (DVT) in patients. A 49-year-old woman presented with left lower limb DVT, which was followed by a diagnosis of MTS on a background of polycystic ovary syndrome (PCOS) and hypothyroidism. MTS is more common among women in the second to fourth decades of life. An endovascular approach is the preferred first-line treatment for MTS.</p> Anne Manjalee Liyanage Tahir Shafiq Vitthal Ramchandra Wadekar Naveed Sultan Fares Abdulla ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-06-06 2018-06-06 5 5 10.12890/2018_000899 Seronegative Bilateral Symmetrical Inflammatory Polyarthritis: Think Twice Before Starting Immunosuppression https://ejcrim.com/index.php/EJCRIM/article/view/895 <p>The most common cause of bilateral symmetrical polyarthritis in the small joints is rheumatoid arthritis. However, if seronegative arthritis is involved, it could be the case that other underlying causes need to be diagnosed. This is particularly important for those coming from or living in developing countries where infectious causes should always be considered. The case of a young Nepali woman is presented in this article. She was referred as a case of seronegative rheumatoid arthritis for DMARDs therapy but this was not the case due to her origin from Nepal and seronegativity for RF, Anti-ccp, and ANA as well as faint macular skin lesions over her face and upper extremities, which the patients are not aware of. Consequently, skin biopsy was carried out which subsequently confirmed that the infectious cause of her polyarthritis was leprosy.</p> Omar Alsaed Nawal Hadwan Izzat Khanjar Abdul-Wahab Al-Allaf ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-06-04 2018-06-04 5 5 10.12890/2018_000895 A Case of Tracheomalacia in Chronic Obstructive Pulmonary Disease: What Went Wrong? https://ejcrim.com/index.php/EJCRIM/article/view/906 <p>Tracheobronchomalacia is defined as loss of the structural integrity of airway wall cartilaginous structures with hyperdynamic airway collapse during respiration. It is a common finding in chronic obstructive pulmonary disease (COPD) but is not always symptomatic, especially if airway narrowing is mild. Symptoms and signs develop as the severity of airway narrowing progresses. When a patient is symptomatic, a prompt study with computerized tomography and flexible bronchoscopy is mandatory for future management. We present a case of tracheobronchomalacia in a patient with COPD whose diagnosis and treatment were challenging.</p> Carmen Tavares Pais Rita Carneiro Silva Teresa Gomes Sónia Carvalho ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-05-31 2018-05-31 5 5 10.12890/2018_000906 An Unusual Case of Primary Retroperitoneal Germ Cell Tumour in a Young Man https://ejcrim.com/index.php/EJCRIM/article/view/900 <p>Some 2–5% of germ cell tumours are of extragonadal origin, with a retroperitoneal location being very rare. The majority of retroperitoneal germ cell tumours have metastasized from a testicular tumour. These tumours are diagnosed incidentally or symptomatically and nearly all present with high alpha-fetoprotein and lactate dehydrogenase levels.<br> We describe the unusual case of a 31-year-old man with a yolk-sac, retroperitoneal germ cell tumour, with normal serum alpha-fetoprotein and lactate dehydrogenase levels, which has not previously been described. A testicular tumour was excluded by physical examination and additional tests. Our diagnosis was based on a high level of suspicion and histopathological results. As far as we know, this is the first case described with these characteristics.</p> Maria João Raposo Linhares Serpa Susana Franco Diana Repolho Francisco Branco João Gramaça José Ferreira Júnior ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-05-29 2018-05-29 5 5 10.12890/2018_000900 Inflammatory Syndrome as the Initial Manifestation of Retroperitoneal Tuberculosis in a Pregnant Woman https://ejcrim.com/index.php/EJCRIM/article/view/865 <p>A 20-year-old asylum seeker presented with vomiting and left thigh pain, with a biological inflammatory syndrome. Pregnancy was diagnosed. Investigations revealed a pseudo-cystic, 20-cm-long retroperitoneal abscess, biopsy of which confirmed the diagnosis of tuberculosis. Evolution after cyst drainage and under conventional anti-tuberculosis treatment was favourable. An abdominal location of tuberculosis is rare and its diagnosis is difficult especially in countries with a low incidence of the disease. Unexplained abdominal manifestations and/or persistent biological inflammatory syndrome, especially in high-risk groups, should raise the suspicion of tuberculosis.</p> Marwene Grira Michel Boulvain Jean-Paul Janssens ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-05-24 2018-05-24 5 5 10.12890/2018_000865 Orbital Apex Syndrome Resulting from Mixed Bacterial Sphenoid Sinusitis https://ejcrim.com/index.php/EJCRIM/article/view/905 <p>Orbital apex syndrome (OAS) is an uncommon disorder characterized by visual loss, ophthalmoplegia, ptosis and hypoaesthesia of the forehead<sup>[1]</sup>. OAS may result from a variety of inflammatory, infectious, neoplastic and vascular conditions that cause damage to the superior orbital fissure (with resultant oculomotor (III), trochlear (IV), abducens (VI) and ophthalmic branch of the trigeminal nerve (V1) palsies) and to the optic canal leading to optic nerve (II) dysfunction. This case report describes the clinical development of OAS in a patient with bacterial sphenoid sinusitis.</p> Mengfei Xiong Wai Lun Moy ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-05-22 2018-05-22 5 5 10.12890/2018_000905 An Unusual Case of Large-Vessel Vasculitis https://ejcrim.com/index.php/EJCRIM/article/view/897 <p>We report the case of a previously healthy 35-year-old man who presented with severe abdominal pain, nausea, vomiting and subjective fever and was found to have acute kidney injury, haematuria, leukocytosis and elevated inflammatory markers. An abdominal CT scan showed lobar nephronia of the left kidney complicated by infarction. Subsequent MRI also revealed splenic infarction. Despite IV antibiotics and US-guided perinephric collection drainage, the condition of the patient continued to deteriorate so he underwent total nephrectomy. Serial follow-up CT scans showed multi-level vascular occlusions, bowel ischaemia and splenic infarction. Large-vessel vasculitis was suspected, and pulse steroid therapy was planned. However, the histopathology report of the resected kidney revealed mucor-like fungal infection suggestive of invasive mucormycosis as a cause for the widespread vasculitis. Although IV amphotericin B and caspofungin were started immediately, the patient died a few days later. We report this case to raise awareness that invasive fungal infection can cause large-vessel vasculitis. Immunosuppression for patients from endemic areas should only be considered after an infectious aetiology for vasculitis has been excluded.</p> Omar Suhail Alsaed Yousef M Yahia Hani Ali Malallah Abdulaziz Abdul-Wahab Al-Allaf ##submission.copyrightStatement## https://creativecommons.org/licenses/by-nc-nd/4.0/ 2018-05-17 2018-05-17 5 5 10.12890/2018_000897